USF Scholarship Repository. University of San Francisco. Kathleen L. Shea University of San Francisco,

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1 University of San Francisco USF Scholarship Repository Doctoral Dissertations Theses, Dissertations and Projects 2015 The Effect of Simulation with Debriefing for Meaningful Learning in Courses of Nursing Theory and Practicum on Student Knowledge and Perception of Instruction Kathleen L. Shea University of San Francisco, Follow this and additional works at: Part of the Education Commons, and the Nursing Commons Recommended Citation Shea, Kathleen L., "The Effect of Simulation with Debriefing for Meaningful Learning in Courses of Nursing Theory and Practicum on Student Knowledge and Perception of Instruction" (2015). Doctoral Dissertations. Paper 299. This Dissertation is brought to you for free and open access by the Theses, Dissertations and Projects at USF Scholarship Repository. It has been accepted for inclusion in Doctoral Dissertations by an authorized administrator of USF Scholarship Repository. For more information, please contact

2 The University of San Francisco THE EFFECT OF CLINICAL SIMULATION WITH DEBRIEFING FOR MEANINGFUL LEARNING IN COURSES OF NURSING THEORY AND PRACTICUM ON STUDENT KNOWLEDGE AND PERCEPTION OF INSTRUCTION A Dissertation Presented to The Faculty of the School of Education Learning and Instruction Program In Partial Fulfillment of the Requirements for the Degree Doctor of Education by Kathleen Shea San Francisco December 2015

3 THE UNIVERSITY OF SAN FRANCISCO Dissertation Abstract The Effect of Simulation with Debriefing for Meaningful Learning in Courses of Nursing Theory and Practicum on Student Knowledge and Perception of Instruction Nursing students are expected to apply knowledge from lectures and laboratories to the clinical setting. One major challenge of nursing educators is facilitating the transfer of knowledge to the clinical-practice setting. Simulation-based education provides students with an experiential-learning activity within the context of a simulated clinical environment. Following the simulation activity, the instructor facilitates a debriefing session and guides student discussion and reflection related to the experience. Debriefing promotes understanding of nursing concepts (Benner, Sutphen, Leonard, & Day, 2010). The purpose of this research is to compare two debriefing methods: traditional method and Debriefing for Meaningful Learning DML (Dreifuerst, 2012). Using a mixed method design, the researcher examined whether there were differences in student knowledge and perceptions of instruction based on debriefing method. Data collection included midterm examination scores, Debriefing Assessment for Simulation in Healthcare-Student Version (DASH-SV) scores on perceptions of instruction, DML worksheets, and a Simulation and Debriefing Experience questionnaire. Additionally, a correlation between examination scores and DASH-Scores was calculated. The researcher invited a class of undergraduate nursing students enrolled in a pediatric nursing theory course to participate in the research. Participants completed ii

4 demographic forms and consents. Each student group of 8 attended a 4-hour simulation session and participated in 4 simulation scenarios involving a 6-month old patient. Simulation scenario concepts included infant growth and development, respirator, and neurology systems. The researcher facilitated the debriefing sessions utilizing the DML or traditional method. Data were analyzed through descriptive statistics and independent samples t test. There were no statistically significant differences in examination scores or DASH-SV scores based on debriefing method. There was a moderate correlation (r=.40) between examination scores and DASH-SV scores. Data from the DML and the Simulation and Debriefing questionnaire suggested that students valued the nursing role, teamwork, and communication experiences during the simulation. Students offered feedback that has implications for practice and future debriefing research. iii

5 This dissertation, written under the direction of the candidate s dissertation committee and approved by the members of the committee, has been presented to and accepted by the Faculty of the School of Education in partial fulfillment of the requirements for the degree of Doctor of Education. The content and research methodologies presented in this work represent the work of the candidate alone. Kathleen Shea November 19, 2015 Candidate Date Dissertation Committee Dr. Patricia Busk November 19, 2015 Dr. Mathew Mitchell November 19, 2015 Dr. KT Waxman November 19, 2015 iv

6 DEDICATION My parents were immigrants from the Philippine Islands, their example of hard work and respect for education encouraged me to achieve this educational goal. Although my father had very little formal education, he completed a vocational school in the 1960 s and began working as a machinist in a Palo Alto firm at the dawn of the Silicon Valley era. My mother earned B.A. in Education from the Far Eastern University in the Philippines; she attended night school and worked full time during the day to help her parents and 9 siblings. My beautiful daughter, Loren Shea, was diagnosed with schizophrenia during my second year in the doctoral program. She takes medication every day to relieve the symptoms of her illness; some days she feels as if she cannot go on living. Thankfully, she never gives up and she is continuing to recover. Her strength and ability to continue moving forward has inspired me in many ways. I dedicate this dissertation to my parents, Amado and Lourdes Lloren, because they provided love and a foundation for me to achieve my goals. I dedicate this work to my amazing daughter, Loren Shea, who inspires me by facing challenges in her life with dignity and demonstrating perseverance while achieving her goals each and everyday. v

7 ACKNOWLEDGEMENTS I would like to thank my dissertation committee for their guidance and support during the years that I spent at USF and while writing this dissertation. The dissertation process has been a challenging experience and I could not have completed this journey without the support of my committee chair, Dr. Patricia Busk, her energy and dedication are unparalleled. Dr. Mathew Mitchell s intelligence and sense of humor encouraged me to continue with challenging courses and with the writing process. I was honored to have Dr. KT Waxman on my committee; she is an awesome role model for the nursing profession and her expertise in clinical simulation was invaluable. I wish to acknowledge the many friends who stood by me even though I did not call, text, or for weeks or months at a time; I am thankful that you are all still there for me once I finished my final defense. A special thanks to my colleagues, Mr. Ed Rovera, Dr. Meg Gorzycki, Ms. Pamela Howard, and Dr. Stacy Serber who helped me in many ways over the past 6 years. A million thanks to my dear friend, Dr. Lopez who inspired me to continue my education, your support and feedback kept me going when I thought I could not move forward. Last but not least, heartfelt appreciation to the many nursing colleagues who provided love and support throughout my nursing career and academic endeavors. To my husband, Kevin, thank you for your love and encouragement and especially for keeping up with the household activities in my absence. Hugs and kisses to my children Brett, Monette, Brian, and Loren and my grandchildren, Adam and Oliver. I hope that I have made you proud; I am so lucky and grateful to have you in my life. vi

8 TABLE OF CONTENTS Page ABSTRACT... ii SIGNATURE PAGE... iii DEDICATION... iv ACKNOWLEDGEMENTS...vii TABLE OF CONTENTS... viii LIST OF TABLES... xi CHAPTER I. INTRODUCTION... 1 Statement of the Problem... 1 Purpose of the Study... 3 Background and Need... 4 Debriefing: A Process for Guided Reflection... 6 Debriefing Methods... 7 Conceptual Framework Transformative Learning Theory Reflective Practice Theory Social Development Theory Research Questions Significance of the Study Definition of Terms Summary II. REVIEW OF THE LITERATURE Simulation-Based Education: The Role of Experience Postsimulation Debriefing Summary III. METHODOLOGY Research Design Research Setting Sample Population Protection of Human Subjects Interventions Simulation Sessions Traditional NLN Method of Debriefing Debriefing for Meaningful Learning Procedures for Data Collection The Class Visit vii

9 TABLE OF CONTENTS CONTINUED CHAPTER Page III. Unit Examination Instrumentation Debriefing Assessment for Simulation in Healthcare Simulation and Debriefing Questionnaire DML Worksheet Unit Examinations Qualifications of the Researcher Restatement of the Research Questions Data Analysis Summary IV. RESULTS Unit-Examination Scores The DASH-SV Scores Correlation Between DASH-SV and Examination Scores Responses to the Simulation and Debriefing Questionnaire The Most Valuable Component of the Simulation The Least Valuable Component of the Simulation Recommendations for Improvement Responses to the DML Worksheets Responses to Scenario One Responses to Scenario Two Responses to Scenario Three Responses to Scenario Four Summary V. SUMMARY, LIMITATIONS, DISCUSSION, AND IMPLICATIONS. 82 Summary of the Study Summary of Findings Limitations of the Study Discussion of Findings Unit-Examination Scores DASH-SV Scores Correlation Between DASH-SV and Examination Scores Simulation and Debriefing Questionnaire DML Worksheets viii

10 CHAPTER TABLE OF CONTENTS CONTINUED V. Page Implications for Research Implications for Practice Conclusions REFERENCES APPENDIXES APPENDIX A: Consent to Participate APPENDIX B: Letter of Invitation to Students APPENDIX C: Information about Research Study APPENDIX D: Student Demographic Survey APPENDIX E: Simulation Preparation Handout APPENDIX F: Simulation and Debriefing Questionnaire APPENDIX G: Simulation Scenario Overview ix

11 Table LIST OF TABLES Page 1. Demographics of Participants Examination Subscores for DML and NLN Groups DASH-SV Scores for DML and NLN Groups Correlation Coefficients for the DASH-SV and Examination Subscores The Most Valuable Component of the Simulation and Debriefing Experience The Least Valuable Component of the Simulation and Debriefing Experience Participant Recommendations for Improvement of the Simulation Experience Scenario One-First Reactions to Simulation Experience Scenario One-What Went Well? Scenario One-What Would you do Differently? Scenario Two-First Reactions to the Simulation Experience Scenario Two-What Went Well? Scenario Two-What Would you do Differently? Scenario Three-First Reactions to the Simulation Experience Scenario Three-What Went Well? Scenario Three-What Would you do Differently? Scenario Four-First Reactions to the Simulation Experience Scenario Four-What Went Well? Scenario Four -What Would you do Differently? x

12 LIST OF TABLES CONTINUED Table Page 20. Number of Responses to DML Worksheet Prompts Representative Sample of Verbatim Student Responses to First Prompt Representative Sample of Verbatim Student Responses to Second Prompt Number of Responses to DML Worksheet Prompts xi

13 1 CHAPTER I STATEMENT OF THE PROBLEM In the traditional undergraduate nursing program, students learn nursing theory in classrooms and laboratory settings. Subsequently, students are expected to apply nursing knowledge to patient care in a hospital or outpatient clinical setting during their clinical practicum assignments. Nursing students are required to demonstrate the application of newly acquired nursing knowledge in clinical practice; however, most undergraduate nursing students are not accustomed to working in clinical settings. In an attempt to provide opportunities for nursing students to rehearse the application of nursing knowledge, schools of nursing have implemented creative teaching strategies such as simulation-based education (Benner, Sutphen, Leonard, & Day, 2010). Simulation-based education is an international curriculum standard utilized in undergraduate nursing schools that provides clinical experiences to nursing students within a realistic and nonthreatening or safe environment (Broussard, 2008; Neill & Wotton, 2011; Waxman, Nichols, O Leary-Kelley, & Miller, 2011). The simulated clinical activity takes place in a space designed to look like a hospital or clinic; this environment contextualizes the patient-care experience. Clinically accurate, simulationbased patient-care scenarios are designed to create an authentic environment where nursing students experience a patient encounter, develop clinical judgments, make decisions, and practice the nursing role. After students have participated in the simulation activity, an instructor-led debriefing session occurs. The postsimulation debriefing is a discussion between the participants, the student observers, and the instructor of the class to review a simulated

14 2 clinical activity. During the debriefing, the students have the opportunity to explore their emotions, thought processes, nursing care, and clinical decisions immediately after the simulated clinical activity (Jeffries & Rogers, 2007; Nehring, Ellis, & Lashley, 2002). During the debriefing experience, students receive immediate feedback from instructors and peers regarding their clinical performance. Additional prompts from the instructor aim to help the students understand the connections between the patient data, clinical condition, and the appropriate nursing response (Broussard, 2008; Gaba, 2004; Neill & Wotton, 2011; Ravert, 2004). Prompting and open-ended statements during debriefing assist students in identification of appropriate nursing responses to the patient s physiological condition. The goal of the debriefing experience is to examine the student s understanding about the patient needs, to evaluate the students performance during the simulation activity, to promote student s reflective thinking, and to provide feedback (Dreifuerst, 2009; Fanning & Gaba, 2007; Jeffries, 2005, 2007; Wickers, 2010). Experts agree that the most important component of the simulation experience is the reflection that occurs during the postsimulation debriefing (Cato & Murray, 2010; Decker et al., 2013; Dreifuerst, 2009; Katz, Peifer, & Armstrong, 2010; Neill & Wotton, 2011; Shinnick, Woo, Horwich, & Steadman, 2011). Although the body of literature regarding postsimulation debriefing has grown rapidly since 2010, there are few empirical studies that address specific strategies to support successful debriefing or demonstrate the advantage of using one debriefing method over another (Arafeh, Hansen, Snyder, & Nichols, 2010; Cant & Cooper, 2010; Chronister & Brown, 2012; Dreifuerst, 2009; Fanning & Gaba, 2007; Fey, Scrandis, Daniels, & Haut, 2014; Nehring, Ellis, & Lashley, 2009; Neill & Wotton, 2011). Moreover, debriefing techniques have been

15 3 developed with little objective evidence of their quality or clinical-judgment outcomes (Arafeh et al., 2010; Cant & Cooper, 2010; Mariani, Cantrell, Meakim, Preito, & Dreifuerst, 2013). Raemer et al reported that research is sparse and limited in presentation for all important topic areas where debriefing is a primary variable (p. 52). The current study addressed the gap in the literature regarding postsimulation debriefing and compared postsimulation debriefing methods for differences in knowledge retention as well as perceptions regarding quality of instruction. The following sections contain the purpose of the study, the background and need, the conceptual framework, the research questions, the significance of the study, as well as the definition of terms. Purpose of the Study The purpose of this research is to investigate whether there were differences in retention of knowledge, as evidenced by scores on unit examinations, when undergraduate nursing students participated in a traditional debriefing method compared with students who participated in the Debriefing for Meaningful Learning (DML) method developed by Dreifuerst (2009). Additionally, nursing student s evaluation and perceptions of the quality of instruction were investigated for differences based on the type of debriefing they received. Finally, student perceptions evaluating the quality of instruction were analyzed for correlation with unit-examination scores on questions related to concepts in simulation activities. The researcher was interested in investigating if participant's perceptions of the quality of instruction (DASH-SV scores) correlate with their knowledge retention (exam scores). If the students rate the instruction methods differently, would the difference have any correlation with their knowledge retention? This study may provide information that would be useful for curriculum

16 4 planning and faculty development for simulation and debriefing in undergraduate nursing schools. Quantitative and qualitative data were gathered from undergraduate nursing student's demographic surveys, unit examination scores, and perceptions of instruction using the Debriefing Assessment of Simulation in Healthcare-Student Version (DASH- SV). These instruments do not involve extraordinary instruction. All students completed the DASH-SV and the unit examinations whether or not they choose to participate in the study; informed consent and demographic information were collected from participants. The mixed-methods research was conducted at a public university in the San Francisco Bay Area; the participants were a convenience sample of undergraduate nursing students enrolled in standard pediatric nursing theory and practicum courses. The nursing courses include didactic instruction for the theoretical portion of the course; the practicum experiences occur in actual clinical settings as well as in the clinical simulation setting. Background and Need The American Association for Colleges of Nursing (2008) publication, Essentials in Baccalaureate Education for the Nursing Profession, called for nursing education reform and provided the curricular elements and a framework for transforming nursing education curriculum for the 21 st century. One of the major challenges of nursing educators is to facilitate the transfer and application of theoretical knowledge to the practice setting. Technological innovation coupled with the nursing education reform movement, has moved simulation-based education into the forefront of nursing education. Simulationbased education is a teaching strategy that creates a virtual reality where nursing students can rehearse patient-care and nursing interventions without the risk of harm to actual

17 5 patients. Simulation-based education in nursing provides students with the opportunity to practice the nursing role and perform nursing interventions within the context of a hospital environment (Jeffries & Rizzolo, 2006). In the context of a simulated hospital room furnished with medical supplies, medical equipment, and patient simulators, an authentic environment is created. The authentic environment combined with the simulation experience is believed to create a more memorable learning environment for nursing students. McCaughey and Traynor, (2010) suggested that students who participated in clinical-simulation experiences would be more prepared for actual clinical assignments. Students enter the clinical-simulation setting with nursing knowledge acquired through multiple teaching strategies such as readings, lectures, study groups, homework assignments, quizzes, clinical experience, and laboratory practice. Clinical simulation and debriefing experiences create a contextual frame of reference that will shape the learner s understanding of the situation. Subsequent simulated clinical experiences combined with actual clinical experiences are thought to scaffold and build upon each other, with each new experience adding a new opportunity for intellectual growth and improved performance (Dreifuerst, 2009). Proponents of clinical-simulation posited that the debriefing aspect of simulationbased nursing education is a key component of influence on the development of clinicaljudgment abilities and deep understanding of nursing concepts in undergraduate nursing students (Benner et al., 2010; Decker et al., 2013; Fanning & Gaba, 2007). Methods of debriefing likely evolve from the natural order of human processing: experiencing an event, reflecting upon the event, discussing the event with others, learning from the

18 6 event, and modifying behaviors in future similar events based on the experience (Gaba & Fanning, 2007). The reflective process facilitated by nurse educators during the postsimulation debriefing session is thought to be central to the understanding about how nursing students learn to make clinical decisions in the clinical setting. The focus of the current research was the comparison of postsimulation debriefing methods; debriefing methods are presented in the following section. Debriefing: A Process for Guided Reflection Nursing educators have learned that guided reflections are often the most effective strategy for promoting learning and deep understanding because students often vary widely in their ability to reflect upon their own practice (Lasater, 2011). Consequently, students need guidance to learn what is clinically important to notice and how to develop their clinical thinking (Lasater & Nielsen, 2009). Postsimulation debriefing is a guided-reflection process that supports the development of clinicaljudgment abilities in undergraduate nursing students (Benner et al., 2010; Lasater & Nielsen, 2009). During the debriefing process, nursing students reflect upon their simulation experience and revisit their assessments, nursing interventions, observations, and patient responses. A nurse educator coaches the students to review the patient data and reflect upon the nursing interventions performed in response to the clinical situation presented during the simulation experience. This process facilitates student s analysis of their own thought processes and gives the educator an opportunity to provide feedback and evaluate the student s rationale regarding the nursing interventions performed.

19 7 The reflective process that takes place during a postsimulation debriefing session is thought to be a key element in the development of clinical judgment in nursing (Cantrell, 2008; Cato & Murray, 2010; Jeffries 2007; Katz, Peifer, & Armstrong, 2010). Participants examine and reflect on their own performance and make connections between theoretical knowledge, application of that knowledge, and clinical decisions made in the simulated patient care setting. Gordon and Buckley (2009) revealed that participants rated the debriefing session the most useful part of the simulation experience. Debriefing Methods The traditional and the DML methods were chosen for this study because they have both been utilized in large-scale, multisite nursing-education research within the United States. Jeffries and Rizzolo (2006) used traditional debriefing methods for their research with the National League for Nursing (NLN) that identified a framework for design, implementation, and evaluation of simulation-based nursing education. Dreifuerst s (2012) DML model was utilized by primary investigator, Jennifer Hayden (2014), in collaboration with the National Council of State Boards of Nursing (NCSBN) to investigate the result of replacing 25% of clinical hours with simulation experiences in undergraduate nursing schools. The traditional method is a model first developed by the military for aircraft pilots; the model utilizes a verbal discussion format and is focused on the nonjudgmental evaluation of performance, prompted by facilitators asking participants to describe what went well, what did not go well, and what they would do differently in the future (Decker 2007; Flannagan, 2008; Sawyer & Deering, 2013). The traditional method of debriefing was employed in a large-scale multisite study sponsored by the National League for

20 8 Nursing and the Laerdal Corporation in an effort to address the best teaching and learning practices for simulation-based nursing education (Jeffries & Rizzolo, 2006). Jeffries and Rizzolo s (2006) research resulted in the development of a standard framework for building simulation programs for healthcare education. For the purpose of this research, the traditional method of debriefing was utilized and is referred to as the traditional NLN method. Dreifuerst (2009, 2012) developed the Debriefing for Meaningful Learning (DML) model, a systematic written process designed to assist participants in the release of emotions and to facilitate a critical analysis of the simulation experience. In preparation for an educator-facilitated verbal debriefing session, modeled after the traditional model, a written activity utilizing the DML worksheet guides students through written exercises to promote self-reflection and develop a deeper understanding of nursing concepts. The DML is utilized to guide students beyond reflection and critical thinking andto promote higher thinking skills of clinical judgment and clinical decisionmaking. Moreover, through analysis of the simulation experience, learners are encouraged to visualize future clinical situations that could be informed by the current simulation experience (Dreifuerst, 2012). Because of its widespread use, the DML model of debriefing was utilized in the current study. Rudolph, Simon, Rivard, Dufresne, and Raemer (2007) promoted a verbal discussion format, the advocacy-inquiry method of nonjudgmental debriefing. This method begins with the facilitator stating an observation or assumption related to the simulation activity, then invites the student to validate or explain their own perspective on the observation or assumption. This strategy uses inquiry to test the facilitator s assumption

21 9 about what occurred in the simulation. Additionally, this method prompts students to verbalize their mental representations to help them make sense of their assumptions and articulate their frames of reference (Rudolph et al., 2007). Kuiper, Heinrich, Matthias, Graham, and Bell-Kotwall (2008) described a structured debriefing model, the Outcome Present State-Test model (OTP), of clinical reasoning. The OTP model uses a printed worksheet for students to diagram the patient s present state compared with the desired goal or the outcome state. Using the worksheet, students create and evaluate interactions associated with the patient s nursing diagnosis, then choose the priority focus of care that will address the most important patient issues. The researchers determined that the worksheets provided scaffolding for reflection and review of the clinical reasoning activities during simulation activities. The paucity of studies related to how best to facilitate postsimulation debriefing that enhances learning outcomes, clinical judgment, and decision-making abilities of nursing students underpins the need for the proposed study (Arafeh et al., 2010; Raemer et al., 2011). The focus of this study was to compare the traditional debriefing method and the DML method to gain insight related to students knowledge retention and perceptions of instruction related to simulation-based education. The two debriefing methods utilized in this research include a traditional verbal debriefing component; the DML method adds a written component to the verbal discussion format. As aforementioned, the written DML exercises promote self-reflection and are meant to assist the participant in the development a deeper understanding of nursing concepts (Dreifuerst, 2012).

22 10 Conceptual Framework One important goal of nurse educators is to empower undergraduate nursing students to become autonomous thinkers with the ability to thrive in the complex healthcare environment (Parker & Myrick, 2009). Educators are often challenged with how best to support nursing students in developing clinical judgment and critical-thinking skills (Forneris, 2004; Forneris & McAlpine, 2006) as well as developing knowledge that can be applied to the practice setting (Parker & Myrick, 2009). Postsimulation debriefing has the potential to promote transformative learning through providing nursing students with new experiences. The conceptual framework underpinning the current research is Mezirow s Transformative Learning Theory, Schön s Reflective Practice Theory, and Vygotsky s Social Development Theory; the following subsection describe the conceptual framework. Transformative Learning Theory The basic concept of the transformative learning theory (Mezirow, 1991) is that learners develop an understanding of the world through their experiences, and it is through experience that learners reformulate their cognitive frames. Mezirow s (1991) transformative-learning theory provides the foundation for the analysis of the postsimulation debriefing process in transforming cognitive frames of reference that enable the nursing student to apply nursing theory in the practice setting. The key concepts of Mezirow s (1991) transformative- learning theory reflect three themes related to adult learning: the role of experience, critical reflection, and rational discourse in knowledge development. Although all experiences contribute to the intellectual development of a learner, merely having an experience is not sufficient to

23 11 promote transformation (Merriam, 2004). The learner must engage in reflection and in rational discourse before he or she develops new frames of reference relative to the specific experience (Merriam, 2004). Learners develop a frame of reference for a specific experience that informs subsequent behaviors (Cranton & King, 2003). Postsimulation debriefing relates to the transformative learning theory; through debriefing, students explore and analyze the simulated clinical experience. During debriefing, students participate in rational discourse by addressing a dilemma faced in the simulation activity. The facilitator or students initiate dialogue related to the disorienting dilemmas faced during the simulation experience. Through discussion and guided reflection, in the presence of peers and content experts, students begin to form new frames. During the debriefing sessions, the discussion and the feedback that occurs and its assimilation into the student s cognition are thought to produce long-lasting learning (Gaba & Fanning, 2007). The process of developing new frames of reference or schemas is the central focus of the transformational-learning theory (Mezirow, 1991). Merriam (2004) maintained that one must engage in a developmental process before transformative learning may occur. Contextual experience, reflection, and rational discourse during the debriefing process all contribute to students development of new meanings and frames of reference. Reflective Practice Theory Schön (1987) studied professional learning, learning processes in organizations, and self-reflection practice; his work investigated how students are prepared and how they learned to function in professional-practice occupations such as medicine, counseling, and studio art. Although Schön (1987) did not address the nursing profession,

24 12 his reflective practice theory may be applied to the nursing profession because nursing best practices are supported by the creative application of models, theories, and principles from nursing and behavioral and humanistic sciences (Schön,1987). Schön (1987) proposed that reflection was central to the understanding of what professional practitioners do. Schön (1987) described the concept of the reflective practicum and proposed that students of professional-practice occupations use selfreflection as a method for learning their craft or artistry. Reflective practicum assists students in acquiring the knowledge and skills needed to become competent in unique professional-practice situations (Schön, 1987). Understanding and analyzing what occurred in the clinical-simulation experience is the first step in the development and transformation of student thinking about clinical practice. Nursing students are expected to utilize new knowledge gained from the debriefing sessions and to apply that knowledge to actual clinical settings. Reflection is used in debriefing sessions for the purpose of extending thinking about clinical performance and identifying rationale for nursing-care behaviors (Benner et al., 2010). Moreover, guided reflection during debriefing is used to improve critical-thinking skills and assist the nursing student to consider alternative patient-care behaviors that can be applied in future clinical situations (Benner et al., 2010). Social Development Theory Vygotsky s (1978) work in child development has become the foundation for the theory in cognitive development over the past several decades and has become what is known as the Social Development Theory (Moll, 1990). The basic themes of the Social Development Theory are that mental activity is uniquely human and that learning is a

25 13 result of community, social interaction, social relationships, and internalization of culture (Moll, 1990). According to Vygotsky (1978), children and adults construct knowledge with others through social interaction (Moll, 1990). Vygotsky (1978) contended that social interaction and language play a fundamental role in one s cognitive development and learning. By looking at nursing educational practice through the lens of the socialdevelopment theory, the nursing student will construct new knowledge during the postsimulation debriefing activity by experiencing social interaction and dialogue with his or her instructor and peers. Moreover, the social-development theory is represented in nursing by the cultural influences that are embedded throughout the nursing educational process. Educators are responsible for teaching knowledge, skills, and attitudes related to nursing practice as well as teaching and role modeling the expectations of the professional nurse. Nursing standards practice focus on knowledge and attitudes that support patient-centered care and the collaborative efforts of the healthcare team. Through daily social interactions and events in the classroom as well as the clinical settings, nursing students learn to function in the healthcare environment and to interact with a community of nurses, physicians, educators, and healthcare team members. The idea of social interaction preceding individual development underlies Vygotsky s (1978) concept of the zone of proximal development (ZPD). Vygotsky (1978) defined ZPD as the distance between the actual development level as determined by independent problem solving and the level of potential development as determined through problem solving under adult guidance or in collaboration with more capable peers (p. 86). This concept applied to adult learning describes nursing students

26 14 experience in an apprentice model of learning where nursing students are assisted and coached by experienced nurses to develop from their actual development level to their potential development level. Vygotsky (1978) proposed that cognition occurs on the social level and is then internalized for individual development. This sociocultural theory of learning intersects with nursing education and practice because of the underlying constructs of socialization and acculturation that are inherent in nursing practice. Social development theory is demonstrated in the simulation and debriefing activities of nursing students. First, students rehearse nursing care in the context of an authentic hospital environment, the simulation center within a university setting. During the postsimulation debriefing, students meet with a community of peers and educators to discuss and reflect upon the simulation experience. Through the debriefing activity, the students have the opportunity develop new meanings and frames of reference to inform their nursing practice. Aligned with Vygotsky s (1978) social-development theory, students engage first at the social level and then have the opportunity to cognitively internalize their experience. Research Questions 1. To what extent do nursing students who participate in DML debriefing in simulation exercises perform better on unit exams than do students who participate in traditional debriefing? 2. To what extent do nursing students who experience the DML perceive the quality of instruction differently from those students experience the traditional debriefing protocols?

27 15 3. To what extent do perceptions of the quality of instruction correlate with unit examination scores for questions related to concepts in simulation activities? Significance of the Study Cheng et al. (2014) conducted a systemic review and meta-analysis of simulation and debriefing research; they recommended more robust debriefing research comparing debriefing methods and including key characteristics such as duration, educator presence, content, structure, methodology, and use of video. A key component of simulation-based education in healthcare is self-reflection and dialogue during the debriefing session; however, there have been few direct comparisons of various debriefing approaches (Van Heukelom, Begaz, & Treat, 2010). The paucity of studies related to how reflective practice during postsimulation debriefing enhances learning outcomes, clinical judgment, and decision-making abilities of nursing students underpins the need for the current study (Arafeh et al., 2010). The current study attempts to address the gap in the simulation and debriefing literature by investigating the effect of two methods of postsimulation debriefing on learning outcomes of undergraduate nursing students. The aim of the current research is to better understand what participants are experiencing and learning from the simulation experience and whether the structure of the debriefing method affects the participants retention of knowledge as measured by examination scores. The information gathered by the research will inform educators about the influence of the traditional NLN method of postsimulation debriefing compared with the DML method developed by Dreifuerst (2009) in relation to student knowledge retention. Currently, there are approximately 15 doctoral nursing students investigating the use of the DML in the United States (Personal communication Dreifuerst, Nov.

28 ). The current study will add to the body of literature investigating debriefing methods and the effect on knowledge retention in undergraduate nursing students. Investigating the influence of structured debriefing after clinical simulation is the focus of the current study. The comparison of debriefing methods may provide insight into how best to achieve learning objectives using simulation. Moreover, the information from the research may influence the methods of debriefing implemented by undergraduate nursing faculty. The current research will add to the body of knowledge comparing debriefing methods and examining the effect of postsimulation debriefing methods on student learning. Definition of Terms Simulation-based education is a strategy utilized for educating undergraduate nursing students. The strategy uses specialized terms that were defined in this section. Although there may be other definitions associated with the following terms, the definitions provided describe how the terms are used in the proposed study. Active-phase participants are the participants who have been assigned roles in the patientcare scenario. Examples of the assigned roles are primary nurse, secondary nurse, and family member. Clinical decision-making refers to the processes by which nurses and other clinicians make their judgments and includes the deliberate process of generating alternatives, weighing them against the evidence, and choosing the most appropriate response to patterns (Tanner, 2006). Clinical-judgment is an used to describe the interpretation that a nurse makes about patient data such as laboratory findings, physical assessment information or patient

29 17 concerns and the decision intervene in a way that is meant to improve patient outcomes and nursing (Tanner, 2006). Debriefing for Meaningful Learning DML is one level of the independent variable that consists of a systematic written process of note taking used by students immediately after the simulation activity to record reactions and facilitate a critical analysis of the patient encounter. The process includes written exercises designed to promote self-reflection and foster new understanding of nursing concepts (Dreifuerst, 2009). High-fidelity simulation (HFS) is simulation that incorporates a computerized full-body mannequin that can be programmed to provide realistic physiological response to student actions (Cant & Cooper, 2010). Observers [Student observers] are participants who are not assigned to a role in the active phase of the simulation activity. Standards of best practice for simulation recommend student observers during each active phase of the simulation scenario. Observational learning is a valuable learning experience and enables the students to participate in the postsimulation debriefing (Decker et al., 2013) Perceptions of instruction is one of the two dependent variables in the proposed research. Perceptions of instruction were measured using the DASH-SV scores. Postsimulation debriefing is an educator-facilitated process of interaction that involves active participation of the learners and occurs immediately after the simulation activity (Cant & Cooper, 2010). Retention of Knowledge is one of the two dependent variables in the proposed research. Retention of knowledge is a learning outcome that is operationalized by analyzing

30 18 examination scores on questions related to the concepts addressed in the simulation scenarios. Traditional method of postsimulation debriefing is one level of the independent variable (method of debriefing) in the proposed research. The traditional method of postsimulation debriefing is a model of debriefing that uses verbal and nonverbal communication to lead a group conversation; the traditional format is led by a faculty facilitator. The debriefing is focused on the critique of performance; participants describe and discuss their emotional reactions, behaviors that were performed, and behaviors that would be done differently in the future (Decker, 2007; Flannagan, 2008). Summary Simulation-based education is one strategy that nursing educators utilize to prepare nursing students for clinical practice. Simulated clinical experiences give students the opportunity to rehearse nursing skills and practice clinical decision making in a safe environment. Postsimulation debriefing is considered to be the most important component of simulation-based education because it engages students in reflective practice that has the potential to enhance student learning. During the debriefing session, students learn through reflection, discussion, and feedback from instructors and nursing student peers. Moreover, nursing students as well as nursing educators provide a community of practice with which students engage in dialogue related to their experience and their thought processes during the simulated patient experience. The current research compared two methods of debriefing and their effect on knowledge retention and perceptions of instruction. This examination of two methods of debriefing is based on the social-learning theories of Mezirow (1991) and Vygotsky

31 19 (1978) as a conceptual framework: individual reflection leads to transformational learning through student s experience with social discourse, discussion, and dialogue. The literature review provides evidence to support the current research, additionally, the methodology, results, and conclusions are presented in the following chapters.

32 20 CHAPTER II REVIEW OF THE LITERATURE This chapter contains a review of literature supporting simulation-based education and postsimulation debriefing in nursing education in relation to concepts of Mezirow s transformative learning and Vygotsky s (1978) social-development theory. Clinicalsimulation pedagogy is presented through the lens of Mezirow s (1991) three central themes regarding transformative learning: the role of experience, rational discourse, and critical reflection. Additionally, the influence of social interaction and learning in community relative to Vygotsky s (1978) social-development theory were addressed. The chapter is divided into several main sections: (a) simulation-based education: the role of experience, (b) debriefing: the role of critical reflection and rational discourse, and (c) chapter summary. The purpose of the current research was to investigate whether there are differences in retention of knowledge, as evidenced by scores on unit examinations, when undergraduate nursing students participate in debriefing using the traditional National League for Nursing (NLN) method compared with students who participate in the Debriefing for Meaningful Learning (DML) method developed by Dreifuerst (2009). Additionally, nursing student s evaluation and perceptions of the quality of instruction were investigated for differences based on the type of debriefing they received. Finally, student perceptions evaluating the quality of instruction were analyzed for correlation with midterm examination scores on questions related to concepts in simulation activities. Simulation-Based Education: The Role of Experience This section presents literature related to the effect of simulation-based educational practices in nursing education. Research investigating the value of using

33 21 simulation in nursing, outcomes of the simulation experience on student perceptions of learning, confidence, self-efficacy, clinical judgment, and safe nursing practice are presented. Researchers Bambini, Washburn, and Perkins (2009) investigated the effect of simulation in nursing education on the self-confidence of novice nursing students. The purpose of their study was to evaluate the influence of simulation as a teaching and learning method on the self-efficacy of nursing students during their initial reproductivehealth clinical rotation. Bambini et al. (2009) suggested that simulation experiences may promote novice nursing students confidence at clinical sites because of their increased sense of self-efficacy. A total of 112 students completed the pretest, posttest, and follow-up survey in addition to participating in a 3-hour postpartum simulation experience that included eight stations with a variety of learning activities including postpartum assessment, newborn care, newborn assessment, prebriefing, high-fidelity postpartum hemorrhage simulation, and debriefing. Students rotated throughout the stations in groups of four then participated in a debriefing session with faculty who reinforced concepts of patient safety and corrected misconceptions of nursing care offered during the simulation. The summative scores for the pretests and posttests were calculated to ascertain postpartum examination self-efficacy scores. Additionally, the researchers evaluated the student s answers to the open-ended questions and identified common themes. A pairwise comparison analysis of the postpartum examination self-efficacy scores revealed a statistically significant increase in student confidence for performing the postpartum examination following the simulation session. The students also experienced a

34 22 statistically significant increase in confidence levels for performing vital signs, breast examination, assessment of fundus, assessment of lochia, and patient education (Bambini et al., 2009). Qualitative data indicated that students viewed the simulation experience as a valuable learning experience that increased their confidence and their readiness for performing in an actual clinical setting. Three themes were identified based on the comments of the participants: communication, confidence in psychomotor skills, and clinical judgment. The students indicated that they learned the importance of verbal and nonverbal communication with family members as well as with the patient as a result of the simulation experience. Students commented that the simulation experience gave them confidence because they worked through assessments and problem solving in the simulation experience. Moreover, the students reported that they experienced improved clinical judgment because they learned how to prioritize assessment skills, to better identify abnormal assessment findings, and to intervene when necessary. The results of this investigation suggest that clinical simulation can be effective in increasing students self-efficacy in their ability to perform psychomotor skills in the postpartum setting. After experiencing a variety of patient situations, students demonstrated an increase self-efficacy in providing patient care. According to Bandura (2004), Efficacy beliefs influence goals and aspirations, the stronger the perceived selfefficacy, the higher the goals people set for themselves and their commitment to them (p. 145). Feelings of self-efficacy should translate into practice by affecting nursing-care behaviors (Bandura, 2004). Bambini et al. (2009) provided support for the use of clinical simulation experiences in preparation for experiences in actual, real-world clinical